Identify signs and symptoms of COPD exacerbation
Develop and implement treatment plan for COPD exacerbation
Recognize and respond to common complications of COPD exacerbation and treatment
Review pathophysiology of acute COPD exacerbation
Oxygen deliver: NRB, Nebulizer, BVM, BiPAP, BVM
Laryngoscope, ET tube
IV, IV fluids
14G needle for chest decompression
Initial decision making in management should account for patient’s mental status, degree of reversible bronchospasm, prior history of exacerbations (hospitalizations and intubation), specific causes or complications of exacerbation.
Predict and prepare for a physiologically difficult airway
DOPE for a patient who begins to deteriorate on a ventilator
Patients with existing emphysema are at at risk of developing pneumothorax
CXR or U/S can be used to rapidly identify a pneumothorax
Common causes of exacerbation are infection or airway irritant.
Inflammation leads to bronchoconstriction and increased mucus secretions. This causes a V/Q mismatch to occur, which is the primary underlying cause of hypoxemia.
Breath stacking can lead to increased intrathoracic pressure, barotrauma, or obstructed venous return.
Mosier, J. M., Joshi, R., Hypes, C., Pacheco, G., Valenzuela, T., & Sakles, J. C. (2015). The Physiologically Difficult Airway. Western Journal of Emergency Medicine, 16(7), 1109–1117. http://doi.org.ezproxy.pcom.edu:2048/10.5811/westjem.2015.8.27467
Bates CG, Cydulka RK. Chapter 73. Chronic Obstructive Pulmonary Disease. In: Tintinalli JE, Stapczynski J, Ma O, Cline DM, Cydulka RK, Meckler GD, T. eds.Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 7e New York, NY: McGraw-Hill; 2011. http://accessmedicine.mhmedical.com.ezproxy.pcom.edu:2048/content.aspx?bookid=348§ionid=40381539. Accessed May 09, 2018.
62 year old male
Has been experiencing increasing shortness of breath since yesterday, but refused family’s request for medical attention. Was brought to ER by family when he became unable to stay awake.
PMH: COPD Meds: Home O2, Atrovent, Sertraline, Spiriva,
Initial Physical Exam
Alert to painful stimuli. Cyanotic, pursed lip breathing, increased work of breathing with accessory muscle use. Lung sounds diminished in all fields. No peripheral edema. Heart sounds +S1 +S2.
BGL (116 mg/dl), CBC (WBC 12,500, Hb 16 Hct 48, Plt 200K) BMP (Na 140, K 3.5, Cl, 100, Cr .85, BUN 16, HCO3 29) ABG (pH 7.26, pCO2 60, pO2 44 HCO3 29)
Pertinent Imaging/Tests (including U/S, EKG, etc.)
EKG, CXR, U/S
Action to Progress
Obtunded, Respiratory distress
Eyes: open to pain
Provide O2, medication, and select appropriate airway management strategy
Recognize need to rapidly control breathing in a patient with COPD exacerbation and decreased level of consciousness
Tension pneumothorax left lung
Decompress chest. Proceed to 4 if they recognize the pneumothorax and treat within 3 minutes.
If failure to recognize pneumothorax proceed to 4
Recognize potential complication of intubation and PPV in a patient with emphysema.
Clinical and imaging findings to diagnose tension pneumothorax
Employ DOPE for deterioration on ventilator
Request labs and determine patient disposition (ICU admission), end scenario and debrief.
Select appropriate labs and imaging for further management of patient
Sinus bradycardia PEA
Initiate CPR. If pneumothorax recognized within 2 minutes proceed to 4. If not end scenario and debrief